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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202604
Report Date: 10/22/2024
Date Signed: 10/22/2024 02:15:58 PM

Document Has Been Signed on 10/22/2024 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:REINDOLLAR ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
275202604
ADMINISTRATOR/
DIRECTOR:		ADLER, WENDYFACILITY TYPE:
735
ADDRESS:301 REINDOLLAR AVETELEPHONE:
(831) 372-8002
CITY:MARINASTATE: CAZIP CODE:
93933
CAPACITY: 4CENSUS: 5DATE:
10/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Staff George Uy TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On 10/22/24 Licensing Program Analyst (LPA) B. Miranda arrived at the facility unannounced to conduct a case management visit regarding a medication error. LPAs introduced themselves and explained the reason for the visit. Staff allowed LPA into the facility. Administrator was was not available at this time.

LPA previously visited the facility on 8/7/24 & 9/24/24 regarding medication error. Administrator had previously told LPA medications would doubled checked and training would be completed. Staff are scheduled for up coming training. In October LPA was informed of another medication error.

This is a repeat violates, citation and civil penalties were issued.

Exit interview conducted and a copy of this report LIC809, LIC809D, LIC421FC, and appeal rights were provided to Staff George Uy.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2024 02:15 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/22/2024 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: REINDOLLAR ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 275202604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
80075(b)(A)(2)(B)

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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(A) In ARFs, facility staff must receive training from a licensed professional. 2. The licensee ensures that the licensed professional reviews staff performance as the licensed professional deems necessary, but at least once a year.
(B) All staff training shall be documented in the facility personnel files.
This requirement is not met as evidenced by:
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Administrator will submit a plan to LPA.
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Based on observation, interview, & record review the licensee did not comply with regulation listed above. Medication errors are still happening at the facility and training may need to be conducted sooner.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Brenda Chan
LICENSING EVALUATOR NAME:Brianna Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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